U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
Sign up for a Free Account
Stalter AM, Phillips JM, Dolansky MA. QSEN Institute RN-BSN Task Force. J Nurs Care Qual. 2017;32:354-358.
Stalter AM ; Phillips JM ; Dolansky MA; et al. White paper on recommendation for systems-based practice competency. QSEN Institute RN-BSN Task Force. 2017; 32: 354-358
A systems approach to practice has been advocated as a key element of safe medical care. This white paper proposes that systems-based practice be integrated as a nursing competency requirement, including education about organizational leadership and complexity science and systems theory in design.
Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.
Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2017;13:162-168.
Implementing human factors in clinical practice.
Timmons S, Baxendale B, Buttery A, Miles G, Roe B, Browes S. Emerg Med J. 2015;32:368-372.
Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005.
Taylor CJC, Murphy MF, Lowe D, Pearson M. Qual Saf Health Care. 2008;17:239-243.
2018 International Symposium on Human Factors and Ergonomics in Health Care.
Human Factors and Ergonomics Society. March 26–28, 2018; Marriott Copley Place, Boston, Massachusetts.
Patient Safety Certificate Program.
Armstrong Institute for Patient Safety and Quality. March 12-16, 2018; Constellation Energy Building, Baltimore, MD.
FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2018.
A system-based approach to managing patient safety in ambulatory care (and beyond).
Burger C, Eaton P, Hess K, et al. Patient Saf Qual Healthc. December 12, 2017.
The SAGES Fundamental Use of Surgical Energy program (FUSE): history, development, and purpose.
Fuchshuber P, Schwaitzberg S, Jones D, et al. Surg Endosc. 2017 Dec 7; [Epub ahead of print].
To err is human: use of simulation to enhance training and patient safety in anaesthesia.
Higham H, Baxendale B. Br J Anaesth. 2017;119(suppl 1):i106-i114.
Safe labeling practices to minimize medication errors in anesthesia: 5 case reports and review of the literature.
Prakash S, Mullick P, Kumar A, Pawar M. A A Case Rep. 2017 Nov 27; [Epub ahead of print].
Twelve tips for embedding human factors and ergonomics principles in healthcare education.
Vosper H, Hignett S, Bowie P. Med Teach. 2017 Nov 10; [Epub ahead of print].
Center for Health Care Human Factors.
Armstrong Institute for Patient Safety and Quality.
CVS taps a design legend to reinvent the prescription label. Next stop: the pharmacy.
Kuang C. Fast Company. October 4, 2017.
Workarounds are routinely used by nurses—but are they ethical?
Berlinger N. Am J Nurs. 2017;117:53-55.
The Role of Clinical Learning Environments in Preparing New Clinicians to Engage in Patient Safety.
Disch J, Kilo CM, Passiment M, Wagner R, Weiss KB; National Collaborative for Improving the Clinical Learning Environment. Chicago, IL: Accreditation Council for Graduate Medical Education; 2017.
Creating a highly reliable neonatal intensive care unit through safer systems of care.
Panagos PG, Pearlman SA. Clin Perinatol. 2017;44:645-662.
Addressing the Opioid Epidemic: Is There a Role for Physician Education?
Schnell M, Currie J. Cambridge, MA: National Bureau of Economic Research; August 2017. Working Paper No. 23645.
AHRQ Safety Program for Improving Antibiotic Use.
Agency for Healthcare Research and Quality, Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, University of Chicago.
Use of unit-based interventions to improve the quality of care for hospitalized medical patients: a national survey.
O'Leary KJ, Johnson JK, Manojlovich M, Astik GJ, Williams MV. Jt Comm J Qual Patient Saf. 2017;43:573–579.
Administering and monitoring high-alert medications in acute care.
Cajanding JMR. Nurs Stand. 2017;31:42-52.
Health and Social Care Ergonomics: Patient Safety in Practice.
Hignett S, Albolino S, Catchpole K, eds. Ergonomics. 2018;61:1-161.
Improving Diagnosis in Health Care: An Implementation Workshop.
The National Academies of Sciences, Engineering, and Medicine. July 17, 2017; National Academy of Sciences Building, Washington, DC.
The "Quality Minute"—a new, brief, and structured technique for quality improvement education during the morbidity and mortality conference.
Hoffman RL, Morris JB, Kelz RR. JAMA Surg. 2017;152:883-884.
Pictograms, units and dosing tools, and parent medication errors: a randomized study.
Yin HS, Parker RM, Sanders LM, et al. Pediatrics. 2017;140:e20163237.
Factors associated with barcode medication administration technology that contribute to patient safety: an integrative review.
Strudwick G, Reisdorfer E, Warnock C, et al. J Nurs Care Qual. 2018;33:79-85.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
Agency for Healthcare Research and Quality
5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364